When should a patient use an Incentive Spirometer (IS)

When Should a Patient Use an Incentive Spirometer?

Incentive spirometry should be used primarily in the perioperative setting for patients undergoing thoracic surgery, particularly those with COPD or chronic obstructive airway disease, where it can reduce postoperative pulmonary complications and improve lung function when combined with inspiratory muscle training. 1, 2, 3

Clinical Indications for Incentive Spirometry

Perioperative Thoracic Surgery Patients

• Patients with COPD undergoing lung resection benefit most from incentive spirometry, with emerging evidence showing reduced postoperative pulmonary complications in this higher-risk population 2
• Preoperative and postoperative use (2 weeks before and 3 months after surgery) combined with inspiratory muscle training significantly increases actual postoperative FEV1 beyond predicted values—by 570 mL after lobectomy and 680 mL after pneumonectomy 3
• Standard pulmonary rehabilitation without incentive spirometry is safer for COPD patients with bullae, though IS can be considered in carefully selected cases 1

Patients with Chronic Obstructive Airway Disease

• Volume-oriented devices (like Coach) are superior to flow-oriented devices (like Triflo-II) for COAD patients, producing significantly greater chest wall expansion (p=0.041) and abdominal wall expansion (p=0.0056) 4
• 77.3% of COAD patients prefer volume-oriented devices, which require less accessory muscle work and are easier to initiate breathing with (p=0.0058) 4

Outpatient Preventive Use

• Daily incentive spirometry exercises (10 breaths, 3 times daily for 30 days) can increase maximal inspiratory volume by 16% (from 1885 mL to 2235 mL, p<0.0001) in ambulatory patients 5
• This approach should be combined with light exercise (20 minutes, 3 times weekly) and postural drainage 5

Important Caveats and Limitations

Evidence Quality Issues

• Despite widespread belief among healthcare professionals (92.7% consider IS essential), there is limited high-quality evidence supporting its routine use 6
• The discrepancy between clinical practice and evidence is substantial—96.6% of clinicians believe IS prevents atelectasis and 92.5% believe it prevents pneumonia, yet published data supporting these claims is weak 6
• Major limitations include poor patient adherence to prescribed regimens, making it difficult to demonstrate consistent clinical benefit 2

When NOT to Use Incentive Spirometry

• Do not use for screening asymptomatic patients—spirometry (including incentive spirometry) should not be used to screen for airflow obstruction in individuals without respiratory symptoms 1
• Avoid in patients with severe respiratory disease at baseline, those unable to perform deep breathing, or those with fever >100.4°F from non-pulmonary causes 5

Practical Implementation Protocol

Perioperative Protocol (Based on Strongest Evidence)

• Timing: Begin 2 weeks preoperatively, continue for 3 months postoperatively 3
• Frequency: 1 hour per day, 6 times per week 3
• Technique: Combine with specific inspiratory muscle training for maximum benefit 3

General Use Protocol (Based on Survey Data)

• Frequency: Every hour while awake 6
• Repetitions: Average 9.6 breaths per session 6
• Breath hold: 7.8 seconds 6
• Initial target volume: 1,288 mL 6
• Daily improvement goal: 526 mL increase 6

Monitoring Parameters

• Patients should contact their physician if maximal inspiratory volume decreases by ≥20% from baseline 5
• Watch for new cough, fever, or shortness of breath during the exercise period 5

Alternative Approaches to Consider

Early ambulation, deep-breathing exercises, and directed coughing may be equally or more effective than incentive spirometry for preventing postoperative complications, with 74-88% of clinicians rating these as equivalent interventions 6. The choice should prioritize patient mobility and engagement rather than defaulting to incentive spirometry alone.